Deficiencies per Year
20
15
10
5
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Re-Inspection
Census: 49
Capacity: 59
Deficiencies: 19
Nov 18, 2025
Visit Reason
State-compiled facility profile showing 7 inspections from 2021 to 2025 with deficiency history and enforcement actions.
Findings
Across multiple inspections, the facility demonstrated repeated deficiencies related to medication administration and tracking, kitchen sanitation, service plan accuracy, resident health services, and compliance with licensing rules. Several deficiencies were not corrected at revisit inspections, indicating ongoing compliance challenges.
Complaint Details
Complaint investigations conducted on 9/27/2023, 2/1/2024, and 7/7/2021 documented findings related to medication errors, acuity-based staffing tool implementation, and licensing compliance.
Deficiencies (19)
| Description |
|---|
| C0300 - Systems: Medications and Treatments: Failed to ensure a safe medication system and adequate professional oversight. |
| C0302 - Systems: Tracking Control Substances: Failed to have a system for accurately tracking controlled substances administered by the facility. |
| Z0162 - Compliance with Rules Health Care: Failed to provide health care services in accordance with licensing rules. |
| C0000 - Comment: Kitchen inspection findings related to food sanitation and compliance with OARs. |
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to maintain kitchen and food preparation areas in accordance with Food Sanitation Rules. |
| Z0142 - Administration Compliance: Failed to follow licensing rules for Residential Care and Assisted Living Facilities. |
| C0010 - Licensing Complaint Investigation: Complaint investigation findings documented. |
| C0303 - Systems: Treatment Orders: Failed to carry out medication and treatment orders as prescribed. |
| C0010 - Licensing Complaint Investigation: Complaint investigation findings documented. |
| C0361 - Acuity-Based Staffing Tool: Failed to fully implement an Acuity-Based Staffing Tool. |
| C0260 - Service Plan: General: Failed to ensure service plans were updated, reflective of care needs, and provided clear direction. |
| C0270 - Change of Condition and Monitoring: Failed to evaluate and monitor residents specific to evaluated needs and service planned interventions. |
| C0280 - Resident Health Services: Failed to ensure timely assessment of significant changes of condition and update service plans accordingly. |
| C0290 - Res Hlth Srvc: On- and Off-Site Health Srvc: Failed to coordinate care with outside providers and implement recommendations. |
| C0330 - Systems: Psychotropic Medication: Failed to ensure PRN psychoactive medications were given only for specific symptoms and after non-drug interventions. |
| C0455 - Inspections and Investigation: Insp Interval: Failed to ensure relicensure survey plan of correction was implemented and satisfied the Department. |
| Z0163 - Nutrition and Hydration: Failed to ensure individualized nutrition and hydration plan for residents. |
| Z0164 - Activities: Failed to evaluate and develop individualized activity plans for residents. |
| Z0165 - Behavior: Failed to provide individualized service plan for behavioral symptoms impacting residents. |
Report Facts
Inspections on page: 7
Total deficiencies: 20
Total licensing violations: 20
Notices: 4
Licensed beds: 59
Census: 49
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Executive Director | Named in multiple medication and kitchen sanitation findings |
| Staff 2 | Health and Wellness Director / RN | Named in medication administration and oversight findings |
| Staff 3 | Health and Wellness Director LPN | Named in service plan and medication order findings |
| Staff 15 | Medication Technician | Named in medication tracking findings |
| Staff 22 | District Director of Operations | Named in medication system oversight findings |
| Staff 4 | District Director of Clinical Services | Named in medication tracking findings |
| Staff 6 | Dietary Services Director | Named in kitchen sanitation findings |
| Staff 8 | Resident Care Coordinator | Named in service plan and care coordination findings |
| Staff 9 | Medication Technician / Caregiver | Named in resident health services findings |
| Staff 19 | Regional RN | Named in service plan and medication order findings |
| Staff 20 | Program Coordinator | Named in activity plan findings |
| Staff 21 | Caregiver | Named in behavioral plan findings |
| Staff 26 | Dietary Manager | Named in kitchen sanitation findings |
| Staff 27 | Medication Technician | Named in fall risk findings |
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